MEDICARE: KAYLA SULLIVAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11043953	FL

General Provider Information

NPI Number	:	1598627341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA SULLIVAN

Provider Business Mailing Address
First Line	:	1215 PAGANO CT
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-4030
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 PAGANO CT
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-4030
Country	:	US
Telephone Number	:	386-316-3760
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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